The annual meeting of the American College of Rheumatology (ACR) kicked off virtually Thursday, bringing together scientists, medical doctors, patients and others involved in the rheumatology field from around the globe. It will continue for five days with scientific sessions by some of the leading minds in the arena.
COVID-19 Treatments and Vaccines
The opening session included a lecture about inflammation and COVID-19 by Eric Rubin, MD, PhD, editor in chief of the New England Journal of Medicine and chair of Harvard University’s T.H. Chan School of Public Health Department of Immunology and Infectious Diseases. Dr. Rubin discussed studies on the use of different anti-inflammatory drugs — many of them used to treat rheumatic diseases — as potential treatments for COVID-19. Results so far have been conflicting and nothing has emerged as a clear winner, but the studies have helped reveal that certain drugs may be more effective at certain stages of COVID-19 and at certain levels of disease severity.
Dr. Rubin also described the various types of vaccines and the significant challenges to developing safe, effective vaccines. The process typically takes years and large numbers of trial participants, and while a number of COVID-19 vaccines are in the works, he didn’t speculate as to when they would be safe and effective. He did say, however, that he believes many of the vaccines will be inactivated, meaning they will be safe for immunosuppressed people, but it isn’t clear how effective they will be.
With other types of vaccines, studies also have found that vaccinated people don’t have the same decline in immunity over time compared with those who achieve immunity from contracting the disease. He expects the same to be true with a future COVID-19 vaccine.
Another highlight of the opening session was a look at 2020’s rheumatology newsmakers in clinical science, presented by Jinoos Yazdhany, MD, professor of medicine and rheumatology at the University of California at San Francisco. Her top choices:
- Positive news for lupus. A study found the drug anifrolumab (which has not yet been approved by the Food and Drug Administration, FDA) effective for moderate or severely active lupus, excluding severe renal and central nervous system involvement. Another found that belimumab may be a good option for lupus nephritis. What’s more, Dr. Yazdhany says, anifrolumab appears to be effective for skin lesions, and trial participants taking it were able to reduce their glucocorticoid (steroid) doses.
- Better information on dosing and safety of glucocorticoids. Several studies showed that certain vasculitis and rheumatoid arthritis (RA) patients can safely taper their steroid dose (with guidance from their doctor). In addition, even low doses of these steroids in some RA patients may increase the risk of hospitalization infection.
- More evidence about tapering drugs. While remission remains a goal for many patients and physicians, one study this year found that reducing the dose of an anti-tumor necrosis factor (TNF) biologic did not increase flares in participants with early axial spondylitis. And rituximab reduces vasculitis flares in some people over the long-term.
- More information about drug safety. A very large recent study found long-term (five years or more) use of bisphosphonates, used to treat osteoporosis, increases the risk of unusual fractures of the femur (although still rare). Stopping the drug dramatically drops the risk. However, fractures were found to occur more often in women of Asian descent. The upshot, says Dr. Yazdhany: Drug holidays should be recommended for all patients taking these drugs, especially for Asian American women. From a study of methotrexate in people with cardiovascular disease, Dr. Yazdhany extrapolated several side effects, including a “new safety signal regarding skin cancer.” In a large study of colchicine (commonly used to treat gout) in patients with chronic coronary disease, “10% had to drop out, mostly for GI side effects,” she says. “Only 9 out of 10 patients could tolerate colchicine.” However, it did appear to reduce heart attacks and stroke.
- New drugs for spondyloarthritis (SpA). Studies have found drugs that use different pathways, or mechanisms, are effective for these conditions, providing more options for patients. Guselkumab, an interleukin-23 (IL-23) inhibitor, was effective for psoriatic arthritis patients who had not had adequate response to other therapies. And a new Janus kinase (JAK) inhibitor is showing promise for axial-SpA, which could give those patients a pill option.
- Rheumatology drugs as potential COVID-19 treatments. Dexamethasone reduced mortality in patients on ventilators, but had no benefit for patients who were not ventilated and “maybe a hint of harm” for those not receiving oxygen. Lots of studies have been done on hydroxychloroquine in COVID-19 patients as a preventative, Dr. Yazdhany says, and “every single one of them was categorically negative, demonstrating that this drug has no role for the treatment of COVID-19.” The studies also found that even in high doses, hydroxychloroquine rarely leads to cardiac death. Other drugs also are being investigated, but more information is needed about how each affects which group of patients, because there’s a lot of variability, she says. The only drug shown to reduce mortality so far is dexamethasone, and that’s only in certain patients. Referring to a U.K. study of numerous therapies for hospitalized patients, she says, “I think this trial beautifully demonstrates that COVID-19 is not just one disease and that immunosuppressant medications might have a greater role in the later, hyper-inflammatory phases of the disease.” —JILL TYRER